CS Form No.

212
Revised 2017
PERSONAL DATA SHEET
WARNING: Any misinterpretation made in the Personal Data Sheet and the Work Experience Sheet shall cause the filing of administrative/criminal case/s against the person concerned.

READ THE ATTACHED GUIDE TO FILLING OUT THE PERSONAL DATA SHEET (PDS) BEFORE ACCOMPLISHING THE PDS FORM.
Print legibly. Tick appropriate boxes ( ) and use separate sheet if necessary. Indicate N/A if not applicable. DO NOT ABBREVIATE. 1. CS ID No. (Do not fill up. For CSC use only)

I. PERSONAL INFORMATION
2. SURNAME BAJA
NAME EXTENSION (JR., SR) N/A
FIRST NAME JERALYN

MIDDLE NAME BALO

3. DATE OF BIRTH
7/20/1995 16. CITIZENSHIP
(mm/dd/yyyy)

4. PLACE OF BIRTH San Vicente, Prosperidad, Agusan del Sur If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX FEMALE

17. RESIDENTIAL ADDRESS N/A Purok-5

6 CIVIL STATUS SINGLE
House/Block/Lot No. Street
N/A San Vicente
Subdivision/Village Barangay
Prosperidad Agusan del SUR
7. HEIGHT (m) 1.55
City/Municipality Province
8. WEIGHT (kg) 48 ZIP CODE 8500

18. PERMANENT ADDRESS 005 Purok-5

9. BLOOD TYPE B
House/Block/Lot No. Street
N/A San Vicente
10. GSIS ID NO. N/A
Subdivision/Village Barangay
11. PAG-IBIG ID NO. N/A Prosperidad Agusan del Sur
City/Municipality Province

12. PHILHEALTH NO. 18-201349157-8 ZIP CODE 8500

13. SSS NO. 34-6443307-4 19. TELEPHONE NO. N/A

14. TIN NO. 773-887-695-000 20. MOBILE NO. 09654821244

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any) [email protected]

II. FAMILY BACKGROUND

22. SPOUSE'S SURNAME 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

N/A
NAME EXTENSION (JR., SR) N/A Jeyvin Baja Baldos
FIRST NAME 12/11/2018
MIDDLE NAME N/A Arjeyl Baja Baldos 10/13/2021

OCCUPATION N/A
EMPLOYER/BUSINESS NAME N/A
BUSINESS ADDRESS N/A
TELEPHONE NO. N/A
24. FATHER'S SURNAME BAJA
NAME EXTENSION (JR., SR) N/A
FIRST NAME JOSE
MIDDLE NAME LLOREN
25. MOTHER'S MAIDEN NAME

SURNAME BALO
FIRST NAME TEODULFA
MIDDLE NAME DUMADAPAT (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

SCHOLARSHIP/
26. PERIOD OF ATTENDANCE HIGHEST LEVEL/
NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE YEAR ACADEMIC
LEVEL UNITS EARNED
(Write in full) (Write in full) (if not graduated)
GRADUATED HONORS
RECEIVED
From To

ELEMENTARY SAN VICENTE ELEMENTARY SCHOOL PRIMARY EDUCATION 2001 2007 N/A 2007 N/A

SECONDARY SAN VICENTE NATIONAL HIGH SCHOOL HIGH SCHOOL 2007 2011 N/A 2011 N/A

VOCATIONAL /
N/A N/A N/A N/A N/A N/A N/A
TRADE COURSE

BACHELOR'S DEGREE IN AGRICULTURE

COLLEGE MINDANAO STATE UNIVERSITY 2011 2016 N/A 2016 N/A
major in Animal Science

GRADUATE STUDIES N/A N/A N/A N/A N/A N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE 09/12/2022 CS FORM 212 (Revised 2017), Page 1 of 4

IV. CIVIL SERVICE ELIGIBILITY
27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER LICENSE (if applicable)
RATING DATE OF EXAMINATION
SPECIAL LAWS/ CES/ CSEE PLACE OF EXAMINATION / CONFERMENT
(If Applicable) / CONFERMENT NUMBER Date of
BARANGAY ELIGIBILITY / DRIVER'S LICENSE
Validity

N/A

(Continue on separate sheet if necessary)

V. WORK EXPERIENCE
(Include private employment. Start from your recent work) Description of duties should be indicated in the attached Work Experience sheet.
SALARY/ JOB/ PAY
28. INCLUSIVE DATES (mm/dd/ GOV'T
GRADE (if
yyyy) POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY MONTHLY STATUS OF
applicable)& STEP SERVICE
(Write in full/Do not abbreviate) (Write in full/Do not abbreviate) SALARY (Format "00-0")/ APPOINTMENT (Y/ N)
From To INCREMENT

COST OF
1/18/2021 7/30/2021 RSBSA Enumerator DEPARTMENT OF AGRICULTURE 16,000.00 N/A N
SERVICE
VPO Rosario Agri-Industrial Development COST OF
01/25/2017 10/20/18 Quality Control Officer 9,455.00 N/A N
Corporation SERVICE
PHILIPPINE CARABAO CENTER-Central
06/08/2015 09/16/2015 ON THE JOB TRAINEE N/A N/A OJT Y
Mindanao University

(Continue on separate sheet if necessary)

SIGNATURE DATE 09/12/2022 CS FORM 212 (Revised 2017), Page 2 of 4

VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
INCLUSIVE DATES
29. NAME & ADDRESS OF ORGANIZATION
(mm/dd/yyyy) NUMBER OF HOURS POS
(Write in full)
From To

N/A N/A N/A N/A

(Continue on separate sheet if necessary)

VII. LEARNING AND DEVELOPMENT (L&D) INTERVENTIONS/TRAINING PROGRAMS ATTENDED

(Start from the most recent L&D/training program and include only the relevant L&D/training taken for the last five (5) years for Division Chief/Executive/Managerial positions)

INCLUSIVE DATES OF Type of LD

30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS ATTENDANCE ( Managerial/
NUMBER OF HOURS
(Write in full) (mm/dd/yyyy) Supervisory/
Technical/etc)
From To

Animal Welfare Seminar and Workshop 11/23/2017 11/23/2017 8 Technical VPO-R

Dairy Buffalo Production and Management 04/13/2015 05/18/2015 320 Managerial Philippine

Symposium on International Humanitarian Law 11/09/2015 11/09/2015 8 Seminar MINDANA

MINDAN
The Politics of Peace: A Symposium on Contemporary Mindanao Politics 03/09/2012 03/09/2012 8 Seminar

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

NON-ACADEMIC DISTINCTIONS / RECOGNITION M

31. SPECIAL SKILLS and HOBBIES 32. 33.
(Write in full)

COMPUTER LITERATE N/A Society of A

COMMUNICATION N/A Catholic Stu

TEAMWORK N/A

ORGANIZATION N/A

ADAPTIBILITY N/A

ANIMAL WELFARE N/A

ANIMAL WELFARE

COOKING N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE 12/11/2018

SITION / NATURE OF WORK

N/A

CONDUCTED/ SPONSORED BY
(Write in full)

ROSARIO AGGRO-INDUSTRIAL CORPORATION

e Carabao Center at Central Mindanao University

AO STATE UNIVERSITY-SCIENCE LECTURE HALL

NAO STATE UNIVERSITY-Institute of Peace and

Development in Mindanao

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write in full)

Animal Science Students (SASS) organization

udent Organization (Health Ministry)

CS FORM 212 (Revised 2017), Page 3 of 4

 34. Are you related by consanguinity or affinity to the appointing or recommending
chief of bureau or office or to the person who has immediate supervision over you in
Bureau or Department where you will be apppointed,
a. within the third degree?
b. within the fourth degree (for Local Government Unit - Career Employees)?
If YES, give details:

35. a. Have you ever been found guilty of any administrative offense?
If YES, give details:

b. Have you been criminally charged before any court?

If YES, give details:
Date Filed:
Status of Case/s:
36. Have you ever been convicted of any crime or violation of any law, decree, ordinance or
regulation by any court or tribunal?
If YES, give details:

37. Have you ever been separated from the service in any of the following modes:
resignation, retirement, dropped from the rolls, dismissal, termination, end of term, If YES, give details:
finished contract or phased out (abolition) in the public or private sector?
38. a. Have you ever been a candidate in a national or local election held within the last
year (except Barangay election)?
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period
before the last election to promote/actively campaign for a national or local candidate If YES, give details:

39. Have you acquired the status of an immigrant or permanent resident of another
country?
If YES, give details (country):

40. Pursuant to: (a) Indigenous People's Act (RA 8371); (b) Magna Carta for Disabled
Persons (RA 7277); and (c) Solo Parents Welfare Act of 2000 (RA 8972), please answer
a.
the following items:
Are you a member of any indigenous group?
If YES, please specify:
b. Are you a person with disability?
If YES, please specify ID No:
c. Are you a solo parent?
If YES, please specify ID No:

41. REFERENCES (Person not related by consanguinity or affinity to applicant /appointee)

ID picture taken within
NAME ADDRESS TEL. NO. the last 6 months
3.5 cm. X 4.5 cm
(passport size)
MARY JOY JOSOL PROSPERIDAD, AGUSAN DEL SUR 9120145673
With full and handwritten
name tag and signature over
LEMUEL BONGCAYAO BUNAWAN, AGUSAN DEL SUR 9352285074 printed name

Computer generated
ANGILEE LUZADA CORALAT BUTUAN CITY, AGUSAN DEL NORTE 9382463906 or photocopied picture
is not acceptable
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true,
correct and complete statement pursuant to the provisions of pertinent laws, rules and regulations of
the Republic of the Philippines. I authorize the agency head / authorized representative to verify/
validate the contents stated herein. I agree that any misrepresentation made in this document and its PHOTO
attachments shall cause the filing of administrative/criminal case/s against me.

Government Issued ID (i.e.Passport, GSIS, SSS, PRC, Driver's License, etc

) PLEASE INDICATE ID Number and Date of
Issuance
Government Issued ID: Philippine Identification Card

ID/License/Passport No.:2098-4972-3503-4817
Signature (Sign inside the box)
09/12/2022
Date/Place of Issuance: 12/05/2021 PSA OFFICE, MANILA
Date Accomplished Right Thumbmark

BSCRIBED AND SWORN to before me this , affiant exhibiting his/her validly issued government ID as indicated abo

RAMEL F. JAMEN, CAO

Person Administering Oath

CS FORM 212 (Revised 2017), Page 4 of 4

Yes/No Cstat Gender
Yes Single Male
No Married Female
Separated
Widowed